Originally posted on Embrace Imperfection.
One of the critical components to providing effective services or resources for people with gender dysphoria is understanding how they may be impacted by trauma. Trauma from a variety of domains disproportionately impacts members of the LGBT community, including those who experience gender dysphoria. As such, the call to implement trauma-informed care within transgender health care systems has been present for some time. It’s noted in academic research, as well as some standards of care. However, despite communities and resource providers putting a theoretical emphasis on supporting those who seek transgender health care, that theory hasn’t carried over into practice. Why have our systems failed to adopt such a crucial component when attempting to provide care? Subsequently, in light of that failure, whose responsibility is it to ensure that this system is changed? Are there ways that community resources can better support survivors of trauma that are not getting their needs met in other areas? Finally, how can we as a community hold each other accountable for being more considerate of the needs of trauma survivors?
Table of Contents
What Does It Mean to be Trauma-Informed?
The principles of trauma-informed care were first developed by Maxine Harris and Roger D. Fallot in their book Using Trauma Theory to Design Service Systems1. Put simply, the concept behind trauma-informed care is the premise that trauma can impact anyone, at any time, and that having experienced trauma can change a person’s responses to or specific needs from care providers. As a result, individuals seeking to provide support services to trauma survivors have the potential to either facilitate healing or risk re-traumatizing those that seek their support. This potential isn’t limited to professional services, either; any community member has the power to foster either recovery or stagnation in the people we interact with. A simple conversation between two peers can have radically different outcomes depending on how each participant reacts to each other, including their choice of language or their general behaviors and attitudes. Becoming more trauma-informed means understanding that our words, actions, and moral values can impact the overall recovery of another, whether directly or indirectly.
The Substance Abuse and Mental Health Services Administration (SAMHSA) broke it down further in their publication SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach2. SAMHSA emphasized that there were four key assumptions when operating under a trauma-informed approach. They are the “Four ‘R’s”: realization, recognition, responding, and resisting re-traumatization.
- Realization: the expectation that trauma is prominent in people’s lives and that this trauma can impact individuals, families, groups, organizations, and communities as they interact with services. The precise way that trauma can impact individuals, groups, or communities will vary, and can be influenced by additional factors such as race, religion, gender, sexual orientation, and disability. The effects of trauma are not confined to mental or behavioral health; rather, they are present in all domains of wellness, and subsequently all systems of support (including but not limited to child welfare, primary health care, peer-operated or community resources, and criminal justice systems).
- Recognition: individuals seeking to provide trauma-informed services need to be able to recognize signs of trauma. Signs may vary depending on additional factors (e.g. race, religion, gender, sexual orientation, and disability), with different impacted groups often having their own unique patterns to consider when providing support. If possible, trauma assessment may help in recognizing these signs. Training, continuing education, and supervision also strengthen recognition of trauma.
- Responding: the active implementation of trauma-informed principles across all areas within a program, organization, or system. On-going training related to the philosophy and principles of trauma-informed care are provided, consumers of services are actively incorporated into the organization’s efforts toward success, and both leadership and general staff are chosen based on their dedication to maintaining “a culture based on beliefs about resilience, recovery, and healing from trauma” (p. 10). Thus, promises are followed through with clear, honest action, and there are systems in place for accountability when those promises are not kept.
- Resisting re-traumatization: the intentional effort to create spaces that foster growth and recovery for both recipients of services as well as those that provide them. This also includes minimizing the creation of toxic or traumatizing environments that could hinder a person’s recovery, or moving away from practices that could compound a person’s traumatic experience.
From there, SAMHSA described six key principles to a trauma-informed approach: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and change; and cultural historical, and gender issues. Each is essential to supporting all domains of wellness for survivors of trauma.
- Safety: the creation of spaces, culture, and interactions that allow survivors of trauma to feel physically and psychologically safe.
- Trustworthiness and Transparency: the practice of open, honest communication surrounding any changes in structure, policy, or operations. In doing so, an atmosphere of trust is established and maintained.
- Peer Support: the inclusion of peer support and mutual self-help between survivors of trauma, including those with lived experience for specific demographics served. Peer support and mutual self-help provide both parties with the potential to develop balanced, recovery-centered relationships in a way that promotes a unique form of healing. They see their own potential for growth through the inspirational work of people they know “get it.”
- Collaboration and Mutuality: the recognition that survivors of trauma have valuable contributions to professional or community services. Community members are actively included in organization efforts and services provided. Community members are also given the opportunity and supports necessary to consult with organizations to better inform their services.
- Empowerment, Voice, and Choice: the emphasis on building up people’s strengths instead of highlighting their weaknesses. People are given the foundations, support, and resources necessary to exercise their voice when needed, as well as foster growth in establishing new skills or abilities that encourage their recovery. Individuals seeking support are given opportunity to be active participants in the supports they receive.
- Cultural, Historical, and Gender Issues: the active effort to move beyond cultural stereotypes and biases that could serve as barriers to providing effective supports. It also includes the understanding of cultural or historical trauma as experienced by specific groups, as well as the need for specific services based on gender or gender identity.
When Harris and Fallot were originally developing the foundations for trauma-informed care, it was originally in the context of professional services, such as housing services, case management, and addiction treatment. SAMHSA makes it clear that they go beyond professional services and into the community domain. Trauma-informed principles can be just as readily integrated into community supports, whether small groups or large-scale consumer-operated organizations, and even one-on-one conversations if approached with an open mind.
Providing trauma-informed care doesn’t necessarily mean providing direct support for trauma. Rather, the focus is on creating a strong foundation of support regardless of the background of each person seeking support. Trauma can influence their needs for a variety of different kinds of care, as well as their response if or when they do seek that care. People seeking to provide trauma-informed services recognize their limitations when it comes to supporting survivors in specific domains. When they are unable to provide the level of support needed, it becomes pertinent to do what they can to connect them to more specialized resources. Examples of this include, but are not limited to, offering lists of resources available in the community, referrals to specific providers or community resources, providing information on specialized crisis lines, and connecting them with community-based peer support.
Where We Went Wrong
Professionals have been noting the need for trauma-informed care within transgender health care services for some time. Despite this, application has been inconsistent, leading to the inevitable failure to meet the needs of gender dysphoric trauma survivors on a grand scale. Furthermore, there has been a disconnect between the professional and the community worlds. This creates a system where health care providers hold a significant position of power over a community at high risk of trauma and leaving said community with limited foundations to challenge it.
The call first went out in 2012, when Kate A. Richmond, Theodore Burnes, and Kate Carroll released a paper underlining the unique needs of transgender trauma survivors who seek support from clinicians3. They argued that transgender people were at elevated risk of three domains of trauma: interpersonal, self-directed, and collective. As a result, this trauma can impact a person’s well-being, as well as their willingness to trust providers that are supporting them in expressing themselves. Richmond et al. emphasized that implementation of trauma-informed care was essential to providing services for transgender clients. The UCSF Transgender Care Navigation Program followed their lead by incorporating the need for trauma-informed care into their treatment guidelines for providers4. A more detailed explanation was developed by Kristen Eckstrand and Jennifer Potter as part of their resource manual Trauma, Resilience, and Health Promotion in LGBT Patients: What Every Healthcare Provider Should Know5. Several chapters were dedicated to the importance of working with the LGBT community when developing trauma-informed practices.
However, these efforts are still in their fledgling stages, and they haven’t been adopted by industry leaders in transgender health care. The current Standards of Care from the World Professional Association for Transgender Health (WPATH) make no mention of incorporating trauma-informed practices, despite noting that gender dysphoria can co-occur with complex dissociative disorders stemmed from trauma6. While version 8 is in development, there is limited transparency about what changes are being proposed, which is in direct contradiction to the key approaches to trauma-informed care as outlined by SAMHSA. Daniel Karasic, one of the authors of the chapter on mental health care for UCSF, has been speaking at international conferences for draft development of version 8, but the position on implementation of trauma-informed care is unclear. Communication about its contents is sparse, sometimes limited to live tweets from transgender conference attendees taking it upon themselves to fill the gap7. Dr. Ruth Pearce, one of the attendees from WPATH’s 2018 conference, expanded on her experience on her personal website8. She noted how there was a clear barrier between health care professionals and transgender recipients of care (or even transgender care providers). She also emphasized the failure among professionals to hold each other accountable for insensitivity, leaving it on the shoulders of transgender attendees who already feel under pressure to keep a low profile. Similarly, drafts for version 8 haven’t been informed by a community advisory council, unlike previous versions9. This again contradicts the SAMHSA standards for trauma-informed practices; community advisory councils give providers critical insight into the needs of community members while also enabling said members to actively contribute to their care. The very individuals who initially advocated for a trauma-informed approach to transgender health care have failed to carry it through in practice, leaving survivors of trauma in the cold.
There are several underlying issues that have prevented health care providers and community members from becoming trauma-informed. One critical issue is that currently, the expectation is that it’s the professional’s responsibility to be trauma-informed when providing services. While professional responsibility is a factor, this expectation inevitably creates a power imbalance between professionals and community members that seek to contribute to their own care. Community members are unable to exercise their voice and work to inform health care practices if there is a wall of authority crafted between them and the professionals providing services. It also means that said community members are unable to reflect on how they can better inform their own efforts to support peers. Related to this, there are no transgender-specific, peer-centered resources on trauma-informed approaches to organization outside of health care services. If it is only the responsibility of professionals to be trauma-informed, then how can community resources such as respite programs, community centers, and advocacy groups support trauma survivors seeking their assistance? Said community resources are often developed to fill in the gaps left by service providers, and yet they’re not given even the most basic of tools to do so effectively.
Furthermore, information on how to implement trauma-informed approaches become buried in academic and professional sources, making them inaccessible to the general population. This may be due to a lack of communication and transparency, paywalls such as scientific journal subscription or hefty fees for professional manuals, or complicated jargon that the average individual struggles to understand. How, then, are communities and professionals supposed to work together if they’re not even on the same page? How are communities able to transform their efforts for the better if they’re not given the opportunity to grow, or if their contributions are not seen as valuable to the very resources they themselves benefit from?
Finally, information on what trauma-informed support for people with gender dysphoria would look like is sparse. While some material is in development, or available through manuals such as the one written by Eckstrand & Potter, information specific to gender dysphoria is lacking. This includes information or resources on how a person’s traumatic experience may influence their gender dysphoria or their sense of self, and what options are available for that person in pursuit of whole person wellness. There is some literature in support of trauma impacting a person’s connection to their body, including in the context of gender dysphoria10, but it hasn’t been applied in practice nor made readily available to the public. In terms of the little information that is available, interested professionals and community members have to take it upon themselves to seek it out. They are in turn faced with a tangled web of disjointed strings of theory and general resources that cannot be effectively applied to the unique needs of people with gender dysphoria. Those that aren’t interested aren’t exposed to the concept, and those that are are met with a mountain to climb with limited to no support.
Shifting the Paradigm
Transforming systems of care to become more trauma-informed requires a radical shift in cultural understanding. This includes our understanding of gender dysphoria, its potential causes, and what kinds of supports a person may need when trying to alleviate their distress. This means moving away from the idea that gender dysphoria is a condition that needs to be treated and instead moving toward learning about a person’s individual story, their experiences, and ultimately, their unique needs. It also means learning to step back from immediate assumptions about a person’s experience or their health care needs and instead ask what supports they need from others.
Before practices can be change, the very foundation that they’re built upon must change. Presently, gender dysphoria is viewed through the lens of the biomedical model, where biological differences necessitate biological treatments in order to mitigate distress. However, this approaches the issue from an angle of seeing gender dysphoria as something pathological that must be medically cured. It also fails to address a key question: what impact do our lived experiences have on our relationship to our bodies and sense of self? By assuming biomedical approaches to gender dysphoria, we fail to look at the larger picture of each person’s lived experience, and ultimately what supports they may need in moving towards wellness. Thus, a movement toward trauma-informed approaches to gender dysphoria by nature requires distancing ourselves from the question of “what’s wrong with you?” and instead asking “what happened, and how can I help?”
Typically, when people think of trauma-informed services, the assumption is that this only applies to professional fields such as social work, medicine, or human services. However, all resources that seek to support community members can benefit from becoming more trauma-informed in their practices. Even on an individual level, it can be beneficial. Understanding the nature of trauma and how it can influence a person’s sense of self, their relationship to their body, or their behaviors towards others can lead to more productive, empathetic, and healing conversations with other community members who are seeking support. It also means that community members can transform the way these conversations are held on a larger scale, creating a new environment that fosters both individual and community growth instead of stagnation.
As such, the success of such a radical shift in approaches is by nature tied to collective responsibility. If we as community members want services provided to us to be sensitive, compassionate, and effective for everyone’s needs, then pressure needs to be put upon the providers who aren’t holding up their end of the bargain. More critically, said collective efforts need to practice what we preach. If we wish for providers to be more responsive and supportive to the needs of trauma survivors with gender dysphoria, then we in turn need to be sensitive to those needs when supporting each other. This isn’t limited to large-scale organization. The very conversation driving organization needs to change so that all following efforts can be informed appropriately.
Is There a Difference Between Medical and Community Approaches?
Currently, the emphasis on trauma-informed approaches have been centered on professional applications such as mental or primary health care. This includes the implementation of specific requirements, as recognized by both Harris & Fallot and SAMSHA. However, several of these approaches can also be applied to community approaches, while others would need to be adapted or included to better account for differences between professional- and community-led resources.
Reflecting on the four key assumptions as discussed earlier, the following is a breakdown of medical versus community approaches to their application:
Medical Approaches | Community Approaches | |
---|---|---|
Realization: | Realize that the trauma a person seeking services has gone through may influence their coping strategies, general presentation, and willingness to engage with medical providers in various domains. Past experiences may influence the person’s ability to trust medical providers offering care, as they are viewed as being in a position of authority that can be misused. Additionally, past experiences can have a range of manifestations, including impacting a person’s gender dysphoria, and thus they may need trauma-specific resources not otherwise being offered. | Realize that trauma is a common experience within the LGBT community, that it can be influenced by intersecting communities and needs, and its potential impact on a person’s sense of self or their connection to their body (including gender dysphoria). Additionally, the perpetration of trauma is not limited to personal lives, but also in the doctor’s office and in community organization efforts. |
Recognition: | Recognize how trauma manifests in different populations. In the context of the LGBT community, provide education on common traumatic experiences and manifestations within the transgender community and what assessments are available for determining resource coordination or referral. In direct service positions, either actively incorporate the application of trauma screening and assessment, or offer their administration when seeking informed consent for treatment. | Provide community and individual education on the prevalence of trauma within the LGBT community, its potential impact on the sense of self, and what resources a survivor may have available to them. While community services may not be qualified to apply assessments for trauma or related post-traumatic responses, they can increase awareness of the existence of these assessments and consult with providers to increase their overall availability. |
Resisting Re-traumatization: | Organizations providing care restructure their spaces, behavior, and culture to promote wellness and recovery for those seeking care. Practices that have been recognized as potentially causing or compounding trauma are replaced in favor of sensitive, compassionate practices that consider a consumer’s boundaries or right to autonomy. | Advocate for a shift in culture and individual behavior that could perpetrate cycles of trauma and abuse among those seeking support. This would also include the active effort to boost the voices of trauma survivors, while removing known predators from positions of power. |
Responding: | Apply the principles of trauma-informed approaches across the board within the system providing care. The principles of trauma-informed approaches are reflected in staff training materials, agency policies, and leadership operations. Staff on all levels of contact embody a warm, approachable attitude that foster connection with community members. Consumer advisory councils are developed to inform services and/or consumers of the agency’s services are actively incorporated into their board of directors to ensure their voices are heard on major decisions. Resources are allocated to support staff who may be dealing with secondary traumatic stress. | Implement the foundations of trauma-informed approaches into organizational practice within the resource. If educational resources are provided for organizing members, utilize ones that can inform said members of the impact of trauma in their community. Ensure that open and honest communication about operation practices are maintained, and that said practices are informed by members of the community outside of the organizing members. Incorporate a diversity of experiences and perspectives into organizational committees. Share accessible resources with organizing members on how to support themselves when dealing with secondary traumatic stress, including low- or no-income options. Create structures of support where organizing members can reflect with each other about difficult situations without fear of retaliation. |
Shared application of the key principles of trauma-informed care is more straight-forward. All supports for people with gender dysphoria, whether professional- or community-driven, should strive to create psychologically and physically safe environments that are sensitive to the needs of trauma survivors. This fosters an environment of trust and connection between those serving and those served, as well as evening the power differential between groups. Similarly, open and honest communication about policy or administrative changes, funding, and general operations is a valuable practice that ensures the public that support systems can be trusted to keep their word. This includes being transparent about any conflicts of interest, including any that are financially or politically motivated.
One asset that community approaches have, versus many medical-based approaches, is the active integration of those with lived experience into organizational efforts. Peer support and mutual self-help is essential to the success of community-driven resources. Not only is peer support seen as a valuable contribution, as it is people’s direct experience that drive their passion for change, but it can empower survivors into giving back to their community. Barriers to contribution can be broken down, individuals can be given pathways into developing educational or professional qualifications, and leadership skills can be fostered. Professional organizations also make an effort to integrate consumers into their systems of care, though they are sometimes met with resistance both internally and externally. Finally, this direct connection to lived experience sets the foundation for developing resources that are culturally competent, including with tailored responses to specific demographics that may otherwise be underserved by professional organizations.
While there are areas where medical approaches to care can learn from community approaches, community approaches can also learn from specific medical approaches. One such area is hiring or recruitment practices of contributing members. Recruiting community members because they tick the right boxes in terms of personal identity isn’t enough. For effective, truly transformative community action, members need to be counted on to be advocates for trauma-informed principles as well as able to reflect them in their actions toward others. It also means providing systems of support for community members to bring up concerns about potentially predatory members of leadership (such as being able to file a grievance), as well as forms of investigation and ultimately accountability for voiced concerns. Related to this, if a community group is collaborating with professionals that have had concerns levied against them, there needs to be some foundation of support both within and outside of the group for those that are speaking up.
First, We Get Angry. Then, We Act.
We are on the precipice of change, as more people from professional and community spheres express the need for more trauma-informed approaches to gender dysphoria. There has been growing outrage in both spheres about the systematic failure to consider the needs of trauma survivors with gender dysphoria. Yet if we want to see this change truly transform our system of care for everyone involved, that outrage needs to be channeled into collaborative action. Disjointed outcries are not enough. Individual voices are easy to discount, contrasted with the strategical strength of entire communities.
This by nature means changing what we consider community. Different people will have different language for their experiences. Still others will have different understandings of what their needs are when addressing gender dysphoria. To create that strength in numbers, this means connecting with all individuals who presently or have experienced gender dysphoria, regardless of their personal sense of identity. Regardless of people’s sense of identity, anyone who seeks care for gender dysphoria has a stake in how that system is constructed. Listen to people’s stories without judgment, and then come to a consensus on how everyone can support each other in advocating for comprehensive care for all.
The power lies in your hands. Be the change you want to see in the world.
References:
1 Harris, M., & Fallot, R. D. (2001). Using Trauma Theory to Design Service Systems. San Francisco, CA: Jossey-Bass.
2 Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. Retrieved from https://store.samhsa.gov/system/files/sma14-4884.pdf
3 Richmond, K. A., Burnes, T., & Carroll, K. (2012). Lost in trans-lation: Interpreting systems of trauma for transgender clients. Traumatology, 18(1), 45–57. https://doi.org/10.1177/1534765610396726
4 Dickey, L. M., Karasic, D. H., & Sharon, N. G. (2016, May 28). Mental health considerations with transgender and gender nonconforming clients. Retrieved July 30, 2019, from UCSF Transgender Care & Treatment Guidelines website: https://transcare.ucsf.edu/guidelines/mental-health
5 Eckstrand, K., L., & Potter, J. (Eds.). (2017). Trauma, Resilience, and Health Promotion in LGBT Patients: What Every Healthcare Provider Should Know. Cham, Switzerland: Springer International Publishing.
6 Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Retrieved from https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf
7 NotRightRuth. (2018, November 6). Dan Karasic on Chapter X: Managing mental and behavioural health conditions in adults. Trying to be more precise about what it means to have a “mental health issue” that might interact with care. #wpath2018 [Tweet]. Retrieved from https://twitter.com/NotRightRuth/status/1059808089988366336
8 Pearce, R. (2018, November 14). A slow, painful grind: WPATH 2018 conference report. Retrieved July 30, 2019, from Dr Ruth Pearce website: https://ruthpearce.net/2018/11/14/a-slow-painful-grind-wpath-2018-conference-report/
9 Knudson, G. (2018, May 30). RE: RESPONSE TO OPEN LETTER from WPATHopenletter@gmail.com. Retrieved from https://www.wpath.org/media/cms/Documents/Public%20Policies/2018/5_May/WPATH%20Response%20to%20Open%20Letter.pdf
10 Colizzi, M., Costa, R., & Todarello, O. (2015). Dissociative symptoms in individuals with gender dysphoria: Is the elevated prevalence real? Psychiatry Research, 226(1), 173–180. https://doi.org/10.1016/j.psychres.2014.12.045